Failure to Notify PASARR Coordinator After Significant Change in Condition
Penalty
Summary
The facility failed to notify the State PASARR Coordinator or appropriate mental health authority after residents with mental disorders or intellectual disabilities experienced a significant change in condition. For three residents reviewed, documentation and interviews confirmed that required referrals for PASARR Level II evaluations were either delayed or not completed at all. In one case, a resident with major depressive disorder and PTSD was discharged from hospice, which constituted a significant change, but the referral to the PASARR Coordinator was not made promptly. Staff interviews confirmed the delay and acknowledged the expectation for timely notification. Another resident with anxiety disorder and major depressive disorder had a Level I PASARR indicating the need for a Level II referral upon significant change, but there was no evidence of a completed Level II evaluation or timely follow-up with the PASARR Coordinator. Additionally, a resident with bipolar disorder had a significant change in status, but no new or updated PASARR was completed, and the Coordinator was not notified. Staff interviews consistently revealed lapses in following the required notification and referral process after significant changes in condition for residents with mental health or intellectual disability diagnoses.